SPECIAL
REPORT

A
Sick Health Care System

The
continuing and massive exodus of Philippine nurses and doctors to other
countries all over the world is now taking a heavy toll on the country’s
already inadequate health-care system. If not addressed, health experts
warn, the country’s health-care system could collapse.

By
Carlos H. Conde
Bulatlat

The
pediatric ward (left) and the labor room (right) of the Cruzado Community
Hospital in Pikit, North Cotabato. Photos
by Gene Boyd Lumawag

PIKIT,
North Cotabato – For the past eight years, Mary Jane Maximo has been
ministering to the people of this small town in North Cotabato, southern
Philippines. As the head nurse at the only private hospital here, she has
seen the violence and felt the pain that have visited this place, such as
the extreme poverty made worse by the government’s war against Muslim
insurgents in 2003 that devastated the town.

Before
the year ends, Maximo, a 29-year-old mother of one child, will leave the
Cruzado Community Hospital and head for Saudi Arabia, where she would earn
five times more than she’s making now. She’s among the thousands of
Filipino nurses – and doctors -- who seek jobs abroad every year,
leaving behind poorly manned hospitals and clinics across the Philippines.

This
exodus, officials said, is now taking a heavy toll on the country’s
already inadequate health-care system. If not addressed, the country’s
health-care system could collapse, they warn.

“It
can get to you sometimes,” Maximo said of her job. “But I have tried
for years to resist the temptation to quit,” she said. “I became a
nurse because I thought I could be of help,” she added. “I still think
I can be of help, but there are days now when I am convinced that my life
could get better.”

The
lure of better pay abroad and better lives for their families back home
has become so strong that even licensed medical doctors are studying to
become nurses. Dr. Edwin Cruzado, the owner of the Cruzado Community
Hospital here, is one of them. Although he did not say that he would
abandon his hospital soon and seek a nursing job abroad, Cruzado said his
parents and relatives have been trying to persuade him to do just that.

If
Cruzado and Maximo do leave, as well as the other nurses in the 10-bed
hospital who are also planning on leaving, the hospital will most likely
be closed down. And if it continues to operate, its owners will face the
possibility that they might not find the people to run it: "I
wouldn't know where to find replacements," Cruzado said.

“It’s
a national crisis,” said Dr. Bu Castro, president of the Philippine
Medical Association. He said the country's health-care system would
"certainly collapse" if the trend continues.

Castro
said his group has studied the phenomenon and found out that the most
vulnerable areas in this crisis are the rural areas, where most of the
country’s poor live and where health care is, in many instances,
nonexistent. Castro’s group also found out that 80 percent of doctors in
community hospitals in the rural areas are studying to become nurses.

Worrisome
figures

Statistics
show that every year, between 5,000 and 8,000 nurses leave for abroad,
around 2,000 of them former doctors. Castro said the case of doctors
turning into nurses is particularly worrisome because medical schools only
produce an average of 1,000 doctors a year. Considering that the
doctor-to-population ratio here is a low 1 to 26,000, the situation is
alarming, Castro said. (The ideal ratio is 1 doctor for every 6,000
citizens.)

Worse,
the number of Filipinos taking up medical courses is declining fast –
down by 20 percent last year. Several medical schools have, in fact,
closed down, Castro said.

On
the other hand, the enrollment for nursing courses has shot up, from about
20,000 in 1999 to more than 40,000 last year, according to the Philippine
Nurses Association (PNA). In 1999, there were 186 nursing schools; this
year, there are 329 such schools. The demand was such that even computer
schools have started offering nursing courses.

Only
about half of the nurses who graduate end up passing the licensure exam
and fewer still end up being hired abroad. This means, thousands of nurses
still remain in the Philippines. The problem is, they are not inclined to
seek employment in hospitals and clinics here because of the low pay,
according to Ruth Padilla, the president of the PNA. They either find
other jobs or wait until they get hired abroad.

The
average salary of a nurse in the provinces is about $120, sometimes lower.
In contrast, a Filipino nurse in the U.S. could earn between $3,000 to
$4,000 a month. The average salary a doctor in the Philippines gets is
between $300 to $800 a month.

“How
can you not think of leaving when you have a very low salary?” said
Maximo, the rural nurse, who gets about $100 a month.

The
rate of migration is such that a congressman proposed a law requiring
nurses and doctors to practice in the Philippines for two years before
they are allowed to work abroad. Early this week, some 6,000 doctors
signed a covenant pledging to stay and practice in the Philippines before
they consider leaving for abroad.

Then
there’s the huge demand. According to Padilla, Filipino nurses are
probably the most sought after in the world, owing to their better
communication skills and their “caring ways.” Most of these nurses go
to the Middle East, although demand in Europe and the U.S. has been
increasing. According to one estimate, the U.S. would need as many as one
million foreign nurses up to the year 2020.

But
Padilla said there is actually no shortage of nurses and doctors in the
Philippines. “What we have is a shortage of skilled nurses and doctors,
and those who are committed enough to go to the rural areas,” she said.

‘Brain
hemorrhage’

In
a paper he prepared last year, former Health Secretary Jaime Galvez-Tan,
who is now the executive director of the National Institutes of Health at
the University of the Philippines in Manila, warned of a “worsening of
the health crisis already plaguing our country.” Very soon, he said,
“the Philippines will be bled dry of nurses.” He called the situation
a “brain hemorrhage,” not a brain drain.

Two
years ago, the World Health Organization warned that the migration of
nurses from Third World countries would affect the health care system of
these countries. “If the world's public health community does not
correct this trend,” said Dr. Gro Harlem Brundtland, the WHO’s
director-general, “the ability of many health systems to function will
be seriously jeopardized.”

This
is already happening in the Philippines, officials and health experts
said. Various studies and reports have indicated a sharp decrease in the
number of nurses, especially in the rural areas, while health services in
these areas have deteriorated.

And
because hospitals are forced to hire new graduates, the lack of experience
can affect the quality of health care. When his wife gave birth last
month, JB Deveza, a student in Cagayan de Oro City in the southern
Philippines, thought that they would only stay in the hospital for three
or four days. But a slip-up by a young nurse who was new on the job forced
Deveza and his wife to stay two days longer, thus paying more.

“It
was absolutely unnecessary but we had to suffer because of the
incompetence of the nurse,” Deveza said, adding that a more experienced
nurse would have spared them the trouble.

Padilla,
the president of the nurses’ association, said things like this are
bound to happen. Worse, she’s worried that because of the huge demand
for nurses, some schools might take shortcuts, resulting in mediocrity,
which could affect the competitiveness of Filipino nurses.

Across
the country, particularly in the countryside, most public health clinics
– if there are any - only have midwives, who act both as doctor and
nurse. In clinics and hospitals in towns and small cities, the turnover of
doctors and nurses is so fast that administrators are complaining not only
about the cost of training new nurses but also about the poor quality of
service that frequent turnovers create.

Dr.
Jojo Carabeo, the president of the Health Alliance for Democracy, said
recently that the turnover of nurses has been “so rapid due to migration
that many nurses only work in hospitals as trainees for a period of three
to six months and leave soon thereafter. Thus many hospitals are
perpetually staffed by trainees.”

New
nurses often just stay within this period to gain the required credentials
to apply abroad, virtually turning hospitals and clinics into nothing but
training facilities. "The mass production of nurses this year is
massive, so many hospitals end up with no nurses," said Cruzado, the
owner and administrator of the hospital in Pikit.

Government
to blame

Health
experts put the blame squarely on the government for this predicament.
“Salaries of nurses have not been raised and because of the fiscal
crisis, government hospitals can’t hire more,” said Padilla. There is
no incentive for nurses to remain in the country, she said.

Galvez-Tan,
the former health secretary, said in his paper that the Philippines
“will never be able to compete with the salary scales and better
opportunities” in other countries. But, he added, the government cannot
tolerate this trend.

“It
is high time that the present administration implement actions to address
this health threatening situations,” Galvez-Tan said. He suggested,
among others, that the Arroyo administration initiate “high-level”
bilateral negotiations with countries that import Filipino nurses and
doctors, and to lobby for representation in the World Trade Organization
“to regulate and monitor the trading of medical and nursing services.”

Castro,
the medical association president, said the government should give more
attention to doctors and nurses at home. “Talk to them, assure them that
the government is doing something for them,” he said.

Deeper
reason

Beyond
the low pay and the lack of government attention are deeper reasons for
the migration: the contractualization of labor and the government’s
policy of using migrant workers to prop up a weak economy.

In
a recent paper titled “Health Professionals Migration and its Impact on
the Philippines,” Antonio Tujan Jr. of Ibon Foundation said the increase
in the migration of nurses and labor in general “is only a by-product of
contractualization of labor and services in many sectors of the economy as
a result of globalization.” On one hand, he pointed out,” it reduces
the relative cost of labor for the affected enterprises, while on the
other hand it creates new wealth for the service contractors and labor
contractors which take a share of the savings in labor costs through their
fees.”

Tujan
traced labor migration to the government’s labor-export policy that
began during the Marcos years. “This policy has an avowed objective to
earning foreign exchange and easing the unemployment situation.Additionally, the government earns billions of pesos in various
fees and insurance premiums required of contract workers,” Tujan wrote.

Indeed,
economists have said that if not for the more than $7 billion in
remittances these overseas Filipino workers send back home every year, the
Philippine economy would have sunk a long time ago.

And
as long as the economy remains weak, as long as it does not industrialize,
as long as it fails to create jobs locally, Filipino workers can expect a
perpetuation of this labor-export policy. Bulatlat